Individual Health Plan Contract Change Form (For Grandfathered Plans and pre-aca Non-Grandfathered Plans)

Individual Health Plan Contract Change Form (For Grandfathered Plans and pre-aca Non-Grandfathered Plans) FOR OFFICE USE ONLY Group/Billing Unit County/Region Effective Date / / INSTRUCTIONS Please use a ballpoint pen to complete the required information as indicated in Section A. For guidelines regarding changes to your policy, please refer to the South Dakota Individual Under-65 Market Enrollment and Administrative Guide or contact Customer Service using the phone number on the back of your Wellmark ID card. If the policyholder is under age 18, the signature and relationship of a parent or legal guardian is required. Please provide proof of guardianship. If this form is for children only, the policyholder must be the youngest child. Wellmark must receive this form within the annual open enrollment period or within a special enrollment period. If this application is received later than 15 days after your signature date, eligibility for requested coverage and effective date are subject to change. Please submit the completed form (pages 1 through 6) to: email: SDU65@wellmark.com OR Mail: Wellmark Blue Cross and Blue Shield of South Dakota 1601 W Madison Street, Station 338 PO Box 5023 Sioux Falls, SD 57117-5023 A. TYPE OF CHANGE (MARK ALL THAT APPLY) Removing policyholder (Complete sections B, C, D, E, F and L) Adding/removing an eligible individual (Complete sections B, C, D, E and L) Updating tobacco-use status (Complete sections B, E and L) Changing address/phone number (Complete sections B, F and L) Changing benefits (Complete sections B, G, H and L) Adding/removing optional benefits (Complete sections B, H and L) Changing billing options (Complete sections B, I, and L) Cancellation of entire policy (Complete sections B, J, and L) B. EXISTING POLICYHOLDER INFORMATION (PLEASE LIST ON TOP OF EACH PAGE) Existing Policyholder Name (First, Middle, Last) Social Security Number (SSN) or Tax Identification Number (TIN) must be provided for you and every covered member for timely processing. Further review may be necessary if an SSN or TIN is not provided. C. ADDING OR REMOVING POLICYHOLDER, AND/OR OTHER ELIGIBLE INDIVIDUALS *Existing benefits and billing information will remain unless you indicate change(s) on this form. Removing Policyholder: Annual Open Enrollment Period (End date cannot be retroactive.) Active Military Service (Provide documentation) Death Medicare Eligible Eligible for Employer Group Coverage If eligible for employer group coverage: List group name: List carrier name List date of event: / / Cancellation date will be as applicable: During open enrollment, the first of the month following your signature date on this change form Day after death of policyholder or through the end of the month if family policy Date your Medicare Supplement policy becomes effective Date you begin basic training or are called to active military service First of the month following start of employer group coverage (or same day if coverage starts on the first of the month) Adding Eligible Individual: Adoption, placement for adoption or foster care Birth Marriage Gained U.S. citizenship Loss of coverage due to move to South Dakota Court-ordered coverage Returning from military service Loss of group coverage or loss of employer contribution Legal guardianship Involuntary loss of creditable coverage Qualifying event not listed For loss of group or other creditable coverage, please list prior insurance company name and policy ID number: List date of event: / / Your effective date will be assigned as described in Section K: Effective Dates. N-3704 10/14 Page 1 of 6

C. ADDING OR REMOVING POLICYHOLDER, AND/OR OTHER ELIGIBLE INDIVIDUALS *Existing benefits and billing information will remain unless you indicate change(s) on this form. Removing Member: Active military duty service (Please provide copy of military papers, indicating date of entry.) Completion of full-time schooling of a dependent child age 26 or older Death Dependent child reaches age 26 and is not a full-time student or permanently disabled Divorce/annulment/legal separation Marriage of a dependent child age 26 or older Spouse obtains employer group coverage Other, Specify List date of event: / / List name(s) of member(s) removed: If removing a member without an event, your cancellation date will be the first of the month following your signature date on this change form. D. MEMBERS TO BE COVERED List ALL persons to be covered & their relationship to Social Security Full-Time the policyholder Relationship Birthdate Number / Tax Gender Student? Name (First, MI, Last) Identification Number 1 Disabled? 2 Policyholder Self Spouse Spouse Dependent 1 Dependent 2 Dependent 3 Dependent 4 1 Social Security Number (SSN) or Tax Identification Number (TIN) must be provided for you and every covered member. Futher review may be necessary if an SSN or TIN is not provided. 2 Disabled dependents and full-time students age 26 or older must be unmarried to be eligible for coverage as a dependent. Are you, your spouse or any dependents listed above enrolled in Medicare? Yes No If yes, please provide names: E. TOBACCO DECLARATION Yes No I, my spouse or my dependent(s) (if included on this form) have used tobacco during the 12 months immediately preceding the signature date on this form. If yes, please indicate name and relationship: F. ADDRESS/PHONE NUMBER Address (Include Street, PO Box, Building Name/No., Apt No., City, State, Zip) Billing Information (Required, if different than address above) (Include Name and Address of Payor) Phone Number ( ) County Name G. PLAN CHANGES Complete this section to decrease your level of benefits. You must be a resident of South Dakota to change your deductible amount. 1. You may decrease your level of benefits at any time during the year (i.e., increasing the deductible) as long as the change allows you to retain your current plan status as determined by Wellmark (i.e., Grandfathered or non-grandfathered plan) OR 2. You may apply for an ACA (Affordable Care Act) plan during an open enrollment or within a special enrollment period. 1. Select your health plan option by placing a check mark in the box prior to plan deductible level. 2. Select a first of the month effective date: / 1 /. (The earliest an effective can be is the first of the month following your signature date. If you do not list an effective date, the first of the month following your signature date will be assigned. If you do not answer Yes or No for each available optional benefit in Section H, Wellmark will assign optional benefits as covered in your existing policy.) Plan Change Options (Not Available for New Sales) Blue Select Blue Select Plus SM Blue Select Basics SM Blue Priority HSA SM $500 $1,000 $1,500 $2,500 $1,500 Plus Plus $2,000 Plus $2,500 Plus $7,500 Plus $1,500 $3,000 HSA-A HSA-B N-3704 10/14 Page 2 of 6

G. PLAN CHANGES (CONT D) Blue Select Classic Blue Standard Dakota Benefits Series I Plan 2 Plan 4 Plan 5 Plan I Plan II Plan III Plan IV H. OPTIONAL BENEFITS Please indicate Yes or No for each of the following Wellmark optional benefits. If you do not answer Yes or No for each optional benefit, Wellmark will assign optional benefits as covered in your existing policy. Yes No Would you like to have the Contraceptive Coverage Option on your plan? (Available on grandfathered Blue Select Plus and Blue Select Basics Plans. Contraceptive coverage is included with non-grandfathered plans.) Yes No Would you like to have the Supplemental Accident Option on your plan? (Available on Blue Select, Blue Select Plus and Classic Blue I-IV Plans) I. BILLING INFORMATION Plan V Plan VI Plan VII Plan A Plan B $500 $1,000 $10,000 HSA $500 $1,000 $2,000 $3,000 Dakota Benefit Series II $600 $1,200 $2,500 Blue Select Transitions $2,000 Optional Maternity Rider (not available on $5000 plan) Important information is available to you at Wellmark.com/Inform that addresses a number of topics such as a description of the acessibility and availability of services, including a list of providers participating in the managed care network and a description of the drug formulary provisions in the plan including the process for obtaining a copy of the current formulary and how to request an exception to the formulary. You can also obtain this information by calling Wellmark Customer Service at 1-800-831-4818. 1. Yes No Will you be paying the premium through a business account? (If yes, answer a and b) a. If submitting a business check, are you an employee of the business paying the premium? Yes No (If yes, we cannot accept a business check for payment; a personal check must be submitted.) b. Will your premium payments for this coverage be deducted on your federal income tax return other than the special health insurance deduction available to self-employed persons? Yes No (If yes, we cannot accept a business check for payment; a personal check must be submitted.) 2. How do you want to pay for health premiums? Please do not send payment with this form. Note: All billing periods are based on a calendar year. a. Direct Bill. On what basis? Semi-annually Annually b. Use billing information on file with Wellmark. (Available only for those with current Wellmark individual coverage.) c. Automatic Account Withdrawal from Policyholder s account. d. Automatic Account Withdrawal from account other than Policyholder s. If you checked c or d, please complete the following: On what basis? Monthly Quarterly Semi-annually Annually Date of withdrawal: 1st of the month 5th of the Month From: Checking Savings (Please complete form M-3506.) Attach a voided check OR complete the following information: Financial Institution Name: Bank Account Name(s) (exactly as it appears on the account): Financial Institution Routing Number (9 digits): Account Number: State Code (found on your check on top right corner above the date - e.g., 78): If Direct Bill is not selected: I hereby certify that I have read and understand the section below entitled Authorization and Certification, and agree to the terms regarding automatic premium withdrawals as described therein. As the Bank Account Holder, I authorize Wellmark to make automatic withdrawals from the account shown in the amount of the premium and fees. I understand and agree that notices of any premium and fee adjustments provided to the Policyholder shall constitute notice to the undersigned of any such adjustment. This authorization supersedes and replaces any previous authorization given by me for automatic premium withdrawal. Bank Account Holder s Signature (if other than Policyholder) Date / / You may cancel automatic account withdrawal at any time. However, we need to receive your written notification by the 10th of the month before your next scheduled withdrawal. N-3704 10/14 Page 3 of 6

J. CANCELLATION OF ENTIRE POLICY I am requesting cancellation of my entire policy effective / 1 /. I understand Wellmark does not allow cancellation on odd dates, and the earliest available cancellation date is the 1st day of the month after Wellmark s receipt of this request. My coverage will continue through the last day of the month in which I notify Wellmark to cancel. If you have vision and/or dental benefits for any member under age 19 included in my health coverage, these vision and/or dental benefits will be canceled with my health coverage. To cancel automatic account withdrawal, Wellmark must receive this request by the 10th of the month prior to my next scheduled withdrawal. To otherwise stop payment, I will notify my bank. I will be responsible for any associated fees from my bank. K. EFFECTIVE DATES When adding eligible individuals to existing coverage, effective dates will be: Event: Effective Date: Birth Date of birth Adoption, Placement for Adoption or Foster care Date of adoption, placement for adoption or foster care Appointment as a Legal Guardian Date of event Court-ordered Coverage Date of event Marriage First day of the month following the event Returning from Military Service Date of discharge or inactive status from the military service or termination of military health coverage Gained U.S.A. Citizenhip First day of the month following the event Involuntary loss of creditable coverage* First day of the month following the event *Involuntary loss of creditable coverage includes: Exhaustion of COBRA Termination of employment / reduction in hours Death of Policyholder / Certificate Holder Divorce / Dissolution of Domestic Partnership Policyholder / Certificate Holder enrolls in Medicare Loss of Children s Health Insurance Program (CHIP) eligibility No longer a dependent Loss of minimum essential coverage Permanent move to South Dakota Loss of group coverage or loss of employer contribution to group coverage L. AUTHORIZATION, CERTIFICATION AND SIGNATURE I certify that I am legally authorized to make changes in coverage for myself and on behalf of all other persons named on my current policy and on this form. I have further confirmed with all persons named on my current policy and on this form that my signature is binding to change coverage. If I have made changes in my plan selection, I understand that I am applying for coverage as indicated on this form which is underwritten by Wellmark of South Dakota, Inc., doing business as Wellmark Blue Cross and Blue Shield of South Dakota ( Wellmark ), providing the specified individual health care coverage. I further understand that the change requested will not start until this form and the appropriate premium payment amount are received and accepted by Wellmark. The statements and answers set forth in this form are full, true, and correct. I have consulted with each other person named in this form to confirm that information about them is full, true, and correct. I understand that Wellmark will rely on the completeness and truthfulness of the information given in the statements made in this form or by telephone or in writing to Wellmark, and that if I performed an act, practice or omission that constitutes fraud or I have made an intentional misrepresentation of material fact in this form, Wellmark will be entitled to declare coverage applied for void and to refuse allowance of benefits to any person thereunder. Special Enrollment Notification Period For special enrollment events, Wellmark must be notified within 60 days of the event (or 120 days of returning from military service). Please see Section K for effective date information. Tobacco User Status If I answered No to the Tobacco Declaration listing on this form, I understand that I am eligible for a special tobacco non-user rate. If this status changes, I must notify Wellmark immediately. Wellmark may require recertification of this status in the future. If Wellmark determines within the initial two years that this status is incorrect, it will retroactively collect historical differences in premiums before claims will be paid, and the tobacco user rate will be applied on the first of the month following receipt of this information. Blue Priority HSA In the event I have selected Blue Priority HSA coverage on this application, I understand that enrolling in Blue Priority HSA coverage does not guarantee that I am or will be eligible to make contributions to a health savings account or that contributions can be made to a health savings account on my behalf. Eligibility If I become enrolled in Medicare during the term of the benefits policy. I understand that this benefits policy will provide benefits secondary to Medicare unless application of federal law determines this benefit policy must provide benefits primary to Medicare. Providing Social Security Numbers or Tax Identification Numbers In order for Wellmark to report your coverage status to the federal government, you must provide to us your Social Security number or tax identification number and the Social Security numbers or tax identification numbers of all members covered under your coverage. The IRS requires that Wellmark report this information using the Social Security number or tax identification number of the plan member and each dependent. If Wellmark does not have Social Security or tax identification numbers, we will be unable to report and send the information needed to complete federal tax returns. If you have not previously provided your Social Security number or tax identification number to Wellmark for all N-3704 10/14 Page 4 of 6

L. AUTHORIZATION, CERTIFICATION AND SIGNATURE, cont d. members covered under your coverage, you should contact us by calling the Customer Service number on your ID card. If you do not provide the Social Security numbers or taxpayer identification numbers to Wellmark for this purpose, you will be subject to a $50 penalty per violation imposed by the Internal Revenue Service. Health Care Reform Mandates If I currently have a grandfathered health plan, I understand that making a change to my current benefits could potentially change the grandfathered status of my health care plan. If I lose grandfathered status of my health care plan, I may be required to incorporate health care reform mandates that are required of non-grandfathered plans. If I currently have a pre-aca non-grandfathered plan, I understand that making a change to my current benefits may require I move to an ACA health plan. Payment Arrangements Payments for premiums and fees may be made on a calendar month, calendar quarter, semi-annual calendar year or calendar year basis. For example, a monthly payment for premiums and fees would be for the first day of a month through the last day of such month. A quarterly payment would be for any calendar quarterly period, such as January 1 through March 31. A semi-annual payment would be for the period of either January 1 through June 30 or July 1 through December 31. An annual payment would be for January 1 through December 31 of the applicable year. In the event I choose to pay my premium and fees on a quarterly, semi-annual, or annual basis and there is a mid-year increase in the amount of premium(s) and/or fees, I will have the following responsibility with regard to an increase in premium(s) and fees: Quarterly Payments: For quarterly payments, I must pay the remaining quarterly premium and fee payment that includes the premium and fee increase. Semi-Annual Payments: For semi-annual payments, I must pay a bill for a premium and fee payment that equals the difference between the new semi-annual premium and fee amount and the previously paid first semi-annual premium and fee amount. I also will be required to pay a second semi-annual premium and fee amount that includes the premium and fee increase. Annual Payment: For annual payments, I must pay a bill for a premium and fee payment that equals the difference between the new annual premium and fee amount and the previously paid annual premium and fee amount. I understand and agree that Wellmark can change my payment amount at any time and the amount of my periodic premium payment and fee payment, will change as provided in the policy being applied for and from time to time based on changes in my coverage, including but not limited to, changes in benefits, payment obligations (such as deductible, coinsurance and copayments), the number of covered family members, members ages, changes in tobacco user status, or other factors that require adjustments to the total premium and fees. These changes may occur at times other than an annual or other policy renewal. If I have elected to authorize automatic premium withdrawals for payment from a deposit account, I understand that, depending upon the timing of when my application is received and processed, Wellmark reserves the right to withdraw the appropriate amount necessary (including multiple months of payments) to bring my account current with the next regularly scheduled automatic payment. Wellmark will not withdraw any amount above that which is due at the time of withdrawals. Notice may not be provided to me prior to this withdrawal. I understand and agree that I will not receive a paper billing statement but that should I want to be notified of amounts being withdrawn, I can do so by viewing my bill on Wellmark.com prior to my chosen withdrawal date. By visiting Wellmark.com, I can also choose to subscribe to an e-mail notifying me when new billing statements are available which will include my withdrawal amount. I further understand and agree that the automatic withdrawal will change periodically to correspond with the applicable premium and fees. My authorization for automatic withdrawals shall include authorization for automatic withdrawal of any changed amount unless I call or provide my bank with written notice not less than three (3) business days before a scheduled withdrawal to stop the payment. If I call my bank to stop payment, I may be required to provide a written request within fourteen (14) days after my call. I will be responsible for any fee assessed by my bank for stop-payment orders that I make. I may also be charged a returned payment fee of $25 for any automatic withdrawal that is not honored by my bank. I also understand and agree that, if I am applying for coverage within 60 days of a premium change with an effective date prior to the premium change, Wellmark will provide notice of the new rate within a reasonable period of time after the enrollment of my application. Coverage Renewability I understand that coverage is automatically renewed by payment of my premium and applicable fee in advance; that a grace period of 31 day will be granted for the payment of each premium and fee due after the first premium and fee; and that, during this grace period, my policy will continue in force. I understand that Wellmark may terminate my policy if: I fail to pay my premium and fee when due; or I fraudulently use my policy or make an intentional misrepresentation of a material fact under the terms of my policy; or I become ineligible for coverage under this policy; or Wellmark decides to terminate coverage of similar policies by giving written notice prior to termination. In the event Wellmark terminates individual policies of the same coverage, I will be allowed to transfer to the offered replacement policy. Acknowledgement I have read and understand the Authorization and Certification language and hereby confirm the authority of Wellmark to make automatic withdrawals from my deposit account as described therein. This authorization supersedes and replaces any previous authorizations given by me for automatic premium withdrawal. N-3704 10/14 Page 5 of 6

L. AUTHORIZATION, CERTIFICATION AND SIGNATURE, cont d. I have confirmed with all persons named in this contract change form that my signature is binding to secure coverage. I have further confirmed with all persons named in this contract change form that in the event I am not eligible for or removed from the coverage and/or the family coverage is divided into multiple policies, my signature is binding to secure coverage. Any payment will be deposited immediately upon Wellmark s receipt of this contract change form. Existing Policyholder s Signature X Date / / New Policyholder s Signature, if applicable X Date / / Parent/Legal Guardian Signature (if applicant is a minor) X Date / / Parent/Legal Guardian Printed Name and relation to applicant Agent Printed Name Agent No. Agent Signature, if applicable X Date / / Farm Bureau County Number Applicant s Farm Bureau Membership Number (if applicable) N-3704 10/14 Page 6 of 6